Rule 6: Ground design in reality

Rule 6: Ground design in reality

The six rules of good healthcare management and leadership development.


An in-depth, sober understanding of the experience of staff and patients is the essential foundation for all successful development programs. There is no shortcutting this step and no development program should commence without a detailed diagnostic of the everyday context in which leadership and management are experienced.

Organizations that fail to properly analyze their own culture and operational realities before investing in management and leadership programs encounter a number of serious problems. The most common is designing a development scheme to fix issues that, they eventually realize, have nothing to do with management and leadership skills.

Misdiagnosis is most likely to result from confusing competencies with context. So investment goes into people development when in reality structural issues are the root cause, such as responsibility being divorced from autonomy, insufficient data to make decisions, a target-driven culture, or an environment of strategic chaos and churn.

There are many helpful organizational diagnostics available to cut through these complex questions of culture. Some of the key lessons noted by interviewees that have used them repeatedly include:

  • Use an approach that captures multiple levels of context. ‘How we do things around here’ can change dramatically from one level of an organization or system to the next, so don’t confine your analysis just to one layer. There is little point investing in services leadership if the problems lie at the systems level, and likewise in organizational leadership for frontline improvement if the lines of control over operations are impaired.
  • Invest in an independent set of eyes, as purely internal assessments can produce biased results. Some organizations even bring in professional anthropologists to spend time observing working cultures at various levels.
  • If external management tutors or leadership consultants are to be used at any stage of the program, engage them in this ‘grounding’ process. Allow time for them to shadow the teams that they will be working with to understand the day to day feel and workings of the organization.

Finally, it is often forgotten that development activities should also be fun. We have all sat in abstract learning sessions and had our minds never really leave the in-tray piling up back at work. What engages participants is practical learning focused on the real challenges they face in their jobs, as well as a sense of camaraderie with colleagues. The US Military Health Service is a particularly marked example of these principles in practice.

Symptoms of failure:

  • No ongoing input into leadership development strategy by staff, patients and care givers.
  • External trainers have never spent time shadowing staff.
  • Goals of development programs that would be better achieved through role and structural redesign.

Key action for boards:

Commission a comprehensive internal study to understand management and leadership cultures in the organization. This could mean inviting an organizational anthropologist to shadow teams, or a tailored survey.


Case study

Simulating stretching challenges for the US Military Health Service (USA).

After an initial term of service in the military, many health professionals leave for a civilian career. Those who stay form the talent pool for the next generation of leaders, taking the military’s health services into an unpredictable and demanding future. Commanders – heads of the military’s medical treatment centers around the world – need to be prepared for many intensely pressured short and long-term challenges, where failure is both likely and costly.

These roles require more than head knowledge – in particular practical experience of the contexts they will face when crises and critical challenges emerge. As one would expect from the military, therefore, development leans heavily on preparation for the real-world experience of leading. Since 2015, the service’s top-level development program for new Commanders uses a set of live scenarios based on recent real-life examples. These are designed both to develop and test this next generation of leaders under conditions as close as possible to those they might face in the field.

Readings in advance of the program provide content and concepts, leaving time during the course to work though the varied scenarios. Stage by stage, each of these scenarios unfolds, and participants are called to communicate with patients, appear before the media, brief legal advisors and so forth. Next time round there are plans to make them even more immersive, using a computer assisted war-gaming center.

It’s an effective approach to leadership development, but demanding to run. These scenarios took a team of 12 to develop and manage, and will need annual renewal. But they are part of a consistent plan to move away from ‘sage on the stage’ presentations, making more use of participants’ own experience in preparing them for the true context of leadership in the field.

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